J Canc Educ DOI 10.1007/s13187-014-0762-3
Inadequacy of Palliative Training in the Medical School Curriculum Nicholas Chiu & Paul Cheon & Stephen Lutz & Nicholas Lao & Natalie Pulenzas & Leonard Chiu & Rachel McDonald & Leigha Rowbottom & Edward Chow
# Springer Science+Business Media New York 2014
Abstract This report examines the literature on palliative training in the current medical school curriculum. A literature search was conducted to identify relevant articles. Physicians and medical students both report feeling that their training in end-of-life care and in palliative issues is lacking. The literature expresses concerns about the varied and non-uniform approach to palliative care training across medical schools. The authors recommend the development of more palliative training assessment tools in order to aid in the standardization of curriculum involving end-of-life care. In addition, increased exposure to dying patients will aid students in building comfort with palliative care issues. Such a goal may be accomplished through required clerkships or other similar programs. Keywords Palliative . Medical school . End-of-life . Training . Education
Introduction Palliative care for patients nearing the end of their lives first began to receive consideration in the medical school N. Chiu : P. Cheon : N. Lao : N. Pulenzas : L. Chiu : R. McDonald : L. Rowbottom : E. Chow (*) Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada e-mail: [email protected] S. Lutz Blanchard Valley Regional Cancer Center, Radiation Oncology, Findlay, OH, USA
curriculum in the late 1960s [1]. Despite early scrutiny of the field, current literature continues to document the inadequacy of palliative training [1–4], as well as the insufficient attention that is paid to the topic [5]. A collaborative systematic review done in 2004 by the University of Liverpool in the UK and the Dunedin School of Medicine in New Zealand states that 90 % of hospital beds are occupied by individuals with life-threatening chronic conditions, and greater than 40 % of deaths occur in hospitals [6]. In addition, with the advent of enhanced chemotherapy techniques and biologic agents, survival for patients with certain terminal diagnoses, such as those with metastatic colorectal cancer [7] and metastatic breast cancer [8], will increase [7, 8]. With the continually aging population, and a population that will exhibit a longer chronic phase before death, almost all physicians will encounter patients with palliative care needs. With close to 125 million North Americans suffering from one or more chronic diseases [3] and associated healthcare costs amounting to over 75 % of healthcare spending [3], the topic of inadequate palliative care training demands careful attention. The current report documents concerns that are addressed in the literature and discusses potential implementations for the improvement of palliative training in the medical school curriculum.
Methods A search was conducted in Medline (1950 to August 2014). Search terms included combinations of the words: “palliative”, “medical school”, “end-of-life”, “training”, and “education”. The search results were reviewed manually and relevant literature was obtained; articles describing palliative care
J Canc Educ
education and suggestions for its improvement were extracted. Articles written in languages other than English were omitted from consideration. There were no restrictions made on geographic location.
Results In the literature search conducted, 24 articles [1–6, 9–26] and many more abstracts which were not extracted for review, highlighted the inadequacy of palliative training received by physicians. In particular, documented responses to questionnaires by physicians indicated that, regardless of specialty, most practicing physicians do not feel adequately prepared for many chronic care competencies, despite also reporting that medical training had a positive effect on their attitudes toward palliative care [3, 9]. Moreover, junior doctors continue to report palliative care as the area in which they experience the greatest distress and feel the most unprepared to deal with [6, 10, 11]. Medical students have reported similarly in the fact that they feel their training is inadequate and have reported negative emotional reactions to end-of-life care [1, 12]. In a large survey of 1236 physicians conducted by Darer et al. in 2004, most physicians felt that more chronic care education was needed [3], and a survey of 450 general practitioners conducted by Barclay et al. indicated that general practitioners repeatedly express interest in receiving palliative care training [9]. The need for more palliative training in medical schools continues to be a concern presently, as numerous recent articles have continued to echo the sentiment of previous calls for a greater focus on end-of-life care. A recent article in 2013 by Frey et al. [23], which surveyed 598 clinical staff members in a 710-bed hospital, found that only 19 % of the 598 respondents reported having received formal palliative care training. Moreover, 73.7 % responded that they would like formal training. This desire for formal training seems particularly justified, as the study also found that perceived confidence in end-of-life delivery was significantly greater for those clinical staff who had received formal palliative care training. Likewise, another article published in 2013 by Eyigor et al. [24], which surveyed 175 fifth-year medical students, seemed to show similar findings: 64.6 % of the students stated that the education on palliative care was insufficient, and 90.3 % indicated that they had not received any training on communication skills in dealing with palliative care patients. Indeed, a study published in 2014 by Anneser et al. [25], which surveyed 709 students, expressed the conclusion that medical students continue to show a “remarkably high interest in learning palliative care competencies.” And yet another, published in the same year, continued to underscore both the “need to improve education about end-of-life care and management for all health care providers [26].” With a large
agreement in the past and current literature indicating that palliative training in the medical curriculum is lacking, coupled with the interest in increased training, more focus on palliative care in the medical curriculum must be considered. In conducting the literature search, we found that one of the most pressing concerns is the need to standardize the curriculum on palliative care among medical schools. A large body of literature from the past two decades has continually highlighted the large variation in curriculum content, target audience, and time commitment to the teaching of palliative medicine [2, 6, 13–16]. A study done in 2004 by Mari LloydWilliams et al., which reviewed 280 abstracts, arrived at the main conclusion that there is an overwhelming lack of consistency in what is being to taught to medical students [6]. In addition, the report expressed difficulties in recruiting appropriate teachers as well as a lack of focus on the development of appropriate attitudes toward palliative care [6]. A literature review done 3 years later in 2007 seemed to find the same thing, emphasizing a continued lack of standardization in the medical education for palliative training and the need for the establishment of standardized, mandatory core competencies to be taught in medical school. [15] Findings were no different a year later in 2008: Anderson et al. cited the continued significant differences in end-of-life instructions to students among medical schools, and the wide variations in students’ clinical exposures to dying patients [12]. Despite the early persistent warnings and calls for implementation of a more structured system of education, the topic of palliative medicine continues to show the same disordered approach; a recent review published in 2014 of the US medical school surveys on palliative training found that end-of-life care continues to experience diverse and uneven approaches to teaching [16]. The 2014 report done by Horowitz et al. goes on to underscore the importance of palliative training, as is widely agreed upon by medical educators and students in the US [16], and again recommends that basic palliative care competencies be defined and integrated every year into the medical school curriculum [16]. Although Meekin et al. noted in a paper published in 2000 that core competencies have been defined [5], there appears to be a disagreement in the literature as more recent articles continue to call for an arrival of said allegedly attained goal. For example, in a report by AalstCohen et al. published eight years later, it was noted that “At present there are no established guidelines to define what is encompassed by palliative care training and no mandated objectives and competencies on which to base an audit of an institution’s curriculum [13].” The discrepancy is apparent when surveying the literature, especially in the observation that curricular objectives and competencies exist, yet differ from article to article and from school to school. For instance, in a survey of U.S. Physicians in 2004, ten competencies in palliative training are listed to be: geriatric syndromes, chronic
J Canc Educ
pain, nutrition, developmental milestones, end-of-life care, psychosocial issues, patient education, assessment of caregiver needs, coordination of services, and interdisciplinary teamwork [3]. However, in the development of a palliative education assessment tool in 2000, the seven major palliative care domains are listed as: palliative medicine, pain, neuropsychological symptoms, other symptoms, ethics and the law, patient/family/nonclinical caregiver perspectives on end-of-life care, and clinical communication skills [5]. Evidently, the complication lies not in the absence of clear objectives in palliative training, but rather the wide variation in beliefs about what objectives are considered most important from school to school. In order to proceed in evaluating, and subsequently improving the training in palliative care, a more formal consensus on the main objectives of said training must first be established. In order to reach such a consensus, one approach might be to develop a standardized, universally accepted palliative education assessment tool to gage whether widely endorsed, essential educational goals are attained in medical school institutions. In the current literature search undertaken, only one such assessment tool was found to exist [5]. We note that other similar tools may exist elsewhere in the literature but may not have been identified; we therefore note this possibility as one limitation in our review. Nevertheless, the lack of other comparable instruments may suggest that this approach in arriving at a more universal consensus may not have been adequately explored. In 2000, Meekin et al. developed a tool to assess palliative training in medical school called the Palliative Education Assessment Tool (PEAT). The PEAT is composed of seven palliative care domains, with each domain detailing specific objectives for knowledge, attitudes, and skills in the curriculum for a medical school. The purpose of such a tool is described by the authors as useful in enabling educators to describe “a specific, multidimensional aspect of the curriculum and use the information for strategic planning, educational reform, and evaluation [5].” The article introducing the tool has been cited 54 times in the 14year span since its publication, suggesting that it has received some attention and may have been implemented—although it certainly has not been universally accepted as the standardized measure for acceptable palliative education in medical schools. In attempting to reach a consensus on the main objectives of palliative training, it may be wise to develop similar instruments to the PEAT; subsequent assessments of the relative benefits and drawbacks of each instrument can be undertaken to create an assessment instrument that can be more widely agreed upon as an accurate depiction of the main objectives of palliative training. Once such an objective is reached, an implementation of the instrument across medical schools should be considered and mandated if deemed representative and acceptable. In creating a more uniform approach to teaching palliative care in the medical school years, robust palliative care training in residencies will assuredly be made easier to
implement, especially in those specialties where palliative care plays a large role in the day-to-day delivery of care. In addition to the lack of a standardized, adequate, and universal curriculum for palliative training across medical schools, our findings in the literature revealed that many students finished medical school without an exposure to death or dying patients [12, 17, 18]. In addition, mandatory palliative care training in medical school is confined to classroom sessions in the pre-clerkship years, and clinical experiences are often elective [14, 17, 19]. This lack of exposure to death and exposure to clinical experience in the palliative setting likely contributes heavily to the feelings of under-preparation and distress expressed by medical students and physicians discussed previously [1, 3, 6, 9–12]. In a survey of graduating students from the University of Pittsburgh School of Medicine from the years 2001–2006, a correlation was found between exposure to dying patients and positive attitudes and knowledge on the topic. Specifically, students who reported experience with death, either personally or in a professional setting, were statistically more likely (p
Inadequacy of Palliative Training in the Medical School Curriculum Nicholas Chiu & Paul Cheon & Stephen Lutz & Nicholas Lao & Natalie Pulenzas & Leonard Chiu & Rachel McDonald & Leigha Rowbottom & Edward Chow
# Springer Science+Business Media New York 2014
Abstract This report examines the literature on palliative training in the current medical school curriculum. A literature search was conducted to identify relevant articles. Physicians and medical students both report feeling that their training in end-of-life care and in palliative issues is lacking. The literature expresses concerns about the varied and non-uniform approach to palliative care training across medical schools. The authors recommend the development of more palliative training assessment tools in order to aid in the standardization of curriculum involving end-of-life care. In addition, increased exposure to dying patients will aid students in building comfort with palliative care issues. Such a goal may be accomplished through required clerkships or other similar programs. Keywords Palliative . Medical school . End-of-life . Training . Education
Introduction Palliative care for patients nearing the end of their lives first began to receive consideration in the medical school N. Chiu : P. Cheon : N. Lao : N. Pulenzas : L. Chiu : R. McDonald : L. Rowbottom : E. Chow (*) Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada e-mail: [email protected] S. Lutz Blanchard Valley Regional Cancer Center, Radiation Oncology, Findlay, OH, USA
curriculum in the late 1960s [1]. Despite early scrutiny of the field, current literature continues to document the inadequacy of palliative training [1–4], as well as the insufficient attention that is paid to the topic [5]. A collaborative systematic review done in 2004 by the University of Liverpool in the UK and the Dunedin School of Medicine in New Zealand states that 90 % of hospital beds are occupied by individuals with life-threatening chronic conditions, and greater than 40 % of deaths occur in hospitals [6]. In addition, with the advent of enhanced chemotherapy techniques and biologic agents, survival for patients with certain terminal diagnoses, such as those with metastatic colorectal cancer [7] and metastatic breast cancer [8], will increase [7, 8]. With the continually aging population, and a population that will exhibit a longer chronic phase before death, almost all physicians will encounter patients with palliative care needs. With close to 125 million North Americans suffering from one or more chronic diseases [3] and associated healthcare costs amounting to over 75 % of healthcare spending [3], the topic of inadequate palliative care training demands careful attention. The current report documents concerns that are addressed in the literature and discusses potential implementations for the improvement of palliative training in the medical school curriculum.
Methods A search was conducted in Medline (1950 to August 2014). Search terms included combinations of the words: “palliative”, “medical school”, “end-of-life”, “training”, and “education”. The search results were reviewed manually and relevant literature was obtained; articles describing palliative care
J Canc Educ
education and suggestions for its improvement were extracted. Articles written in languages other than English were omitted from consideration. There were no restrictions made on geographic location.
Results In the literature search conducted, 24 articles [1–6, 9–26] and many more abstracts which were not extracted for review, highlighted the inadequacy of palliative training received by physicians. In particular, documented responses to questionnaires by physicians indicated that, regardless of specialty, most practicing physicians do not feel adequately prepared for many chronic care competencies, despite also reporting that medical training had a positive effect on their attitudes toward palliative care [3, 9]. Moreover, junior doctors continue to report palliative care as the area in which they experience the greatest distress and feel the most unprepared to deal with [6, 10, 11]. Medical students have reported similarly in the fact that they feel their training is inadequate and have reported negative emotional reactions to end-of-life care [1, 12]. In a large survey of 1236 physicians conducted by Darer et al. in 2004, most physicians felt that more chronic care education was needed [3], and a survey of 450 general practitioners conducted by Barclay et al. indicated that general practitioners repeatedly express interest in receiving palliative care training [9]. The need for more palliative training in medical schools continues to be a concern presently, as numerous recent articles have continued to echo the sentiment of previous calls for a greater focus on end-of-life care. A recent article in 2013 by Frey et al. [23], which surveyed 598 clinical staff members in a 710-bed hospital, found that only 19 % of the 598 respondents reported having received formal palliative care training. Moreover, 73.7 % responded that they would like formal training. This desire for formal training seems particularly justified, as the study also found that perceived confidence in end-of-life delivery was significantly greater for those clinical staff who had received formal palliative care training. Likewise, another article published in 2013 by Eyigor et al. [24], which surveyed 175 fifth-year medical students, seemed to show similar findings: 64.6 % of the students stated that the education on palliative care was insufficient, and 90.3 % indicated that they had not received any training on communication skills in dealing with palliative care patients. Indeed, a study published in 2014 by Anneser et al. [25], which surveyed 709 students, expressed the conclusion that medical students continue to show a “remarkably high interest in learning palliative care competencies.” And yet another, published in the same year, continued to underscore both the “need to improve education about end-of-life care and management for all health care providers [26].” With a large
agreement in the past and current literature indicating that palliative training in the medical curriculum is lacking, coupled with the interest in increased training, more focus on palliative care in the medical curriculum must be considered. In conducting the literature search, we found that one of the most pressing concerns is the need to standardize the curriculum on palliative care among medical schools. A large body of literature from the past two decades has continually highlighted the large variation in curriculum content, target audience, and time commitment to the teaching of palliative medicine [2, 6, 13–16]. A study done in 2004 by Mari LloydWilliams et al., which reviewed 280 abstracts, arrived at the main conclusion that there is an overwhelming lack of consistency in what is being to taught to medical students [6]. In addition, the report expressed difficulties in recruiting appropriate teachers as well as a lack of focus on the development of appropriate attitudes toward palliative care [6]. A literature review done 3 years later in 2007 seemed to find the same thing, emphasizing a continued lack of standardization in the medical education for palliative training and the need for the establishment of standardized, mandatory core competencies to be taught in medical school. [15] Findings were no different a year later in 2008: Anderson et al. cited the continued significant differences in end-of-life instructions to students among medical schools, and the wide variations in students’ clinical exposures to dying patients [12]. Despite the early persistent warnings and calls for implementation of a more structured system of education, the topic of palliative medicine continues to show the same disordered approach; a recent review published in 2014 of the US medical school surveys on palliative training found that end-of-life care continues to experience diverse and uneven approaches to teaching [16]. The 2014 report done by Horowitz et al. goes on to underscore the importance of palliative training, as is widely agreed upon by medical educators and students in the US [16], and again recommends that basic palliative care competencies be defined and integrated every year into the medical school curriculum [16]. Although Meekin et al. noted in a paper published in 2000 that core competencies have been defined [5], there appears to be a disagreement in the literature as more recent articles continue to call for an arrival of said allegedly attained goal. For example, in a report by AalstCohen et al. published eight years later, it was noted that “At present there are no established guidelines to define what is encompassed by palliative care training and no mandated objectives and competencies on which to base an audit of an institution’s curriculum [13].” The discrepancy is apparent when surveying the literature, especially in the observation that curricular objectives and competencies exist, yet differ from article to article and from school to school. For instance, in a survey of U.S. Physicians in 2004, ten competencies in palliative training are listed to be: geriatric syndromes, chronic
J Canc Educ
pain, nutrition, developmental milestones, end-of-life care, psychosocial issues, patient education, assessment of caregiver needs, coordination of services, and interdisciplinary teamwork [3]. However, in the development of a palliative education assessment tool in 2000, the seven major palliative care domains are listed as: palliative medicine, pain, neuropsychological symptoms, other symptoms, ethics and the law, patient/family/nonclinical caregiver perspectives on end-of-life care, and clinical communication skills [5]. Evidently, the complication lies not in the absence of clear objectives in palliative training, but rather the wide variation in beliefs about what objectives are considered most important from school to school. In order to proceed in evaluating, and subsequently improving the training in palliative care, a more formal consensus on the main objectives of said training must first be established. In order to reach such a consensus, one approach might be to develop a standardized, universally accepted palliative education assessment tool to gage whether widely endorsed, essential educational goals are attained in medical school institutions. In the current literature search undertaken, only one such assessment tool was found to exist [5]. We note that other similar tools may exist elsewhere in the literature but may not have been identified; we therefore note this possibility as one limitation in our review. Nevertheless, the lack of other comparable instruments may suggest that this approach in arriving at a more universal consensus may not have been adequately explored. In 2000, Meekin et al. developed a tool to assess palliative training in medical school called the Palliative Education Assessment Tool (PEAT). The PEAT is composed of seven palliative care domains, with each domain detailing specific objectives for knowledge, attitudes, and skills in the curriculum for a medical school. The purpose of such a tool is described by the authors as useful in enabling educators to describe “a specific, multidimensional aspect of the curriculum and use the information for strategic planning, educational reform, and evaluation [5].” The article introducing the tool has been cited 54 times in the 14year span since its publication, suggesting that it has received some attention and may have been implemented—although it certainly has not been universally accepted as the standardized measure for acceptable palliative education in medical schools. In attempting to reach a consensus on the main objectives of palliative training, it may be wise to develop similar instruments to the PEAT; subsequent assessments of the relative benefits and drawbacks of each instrument can be undertaken to create an assessment instrument that can be more widely agreed upon as an accurate depiction of the main objectives of palliative training. Once such an objective is reached, an implementation of the instrument across medical schools should be considered and mandated if deemed representative and acceptable. In creating a more uniform approach to teaching palliative care in the medical school years, robust palliative care training in residencies will assuredly be made easier to
implement, especially in those specialties where palliative care plays a large role in the day-to-day delivery of care. In addition to the lack of a standardized, adequate, and universal curriculum for palliative training across medical schools, our findings in the literature revealed that many students finished medical school without an exposure to death or dying patients [12, 17, 18]. In addition, mandatory palliative care training in medical school is confined to classroom sessions in the pre-clerkship years, and clinical experiences are often elective [14, 17, 19]. This lack of exposure to death and exposure to clinical experience in the palliative setting likely contributes heavily to the feelings of under-preparation and distress expressed by medical students and physicians discussed previously [1, 3, 6, 9–12]. In a survey of graduating students from the University of Pittsburgh School of Medicine from the years 2001–2006, a correlation was found between exposure to dying patients and positive attitudes and knowledge on the topic. Specifically, students who reported experience with death, either personally or in a professional setting, were statistically more likely (p
